Category B1/B2 according Part-66 Appendix 1 Module 9 Human Factors

Part 66 Cat. B1 / B2 Module 9A

HUMAN FACTORS

Vilnius – 2017

Issue 1. Effective date 2017-03-20 FOR TRAINING PURPOSES ONLY Page 1 of 150
 Category B1/B2 according Part-66 Appendix 1 Module 9 Human Factors

Human Factors in Aviation Maintenance

The first attempts of the thing we can call “Human Factors” appeared in early aviation time as aircraft
compatibility with the humans, and who could be better pilot. The last question was solved through
medical investigations.
After a years, when mass – production started it was realized that the compatibility of aircraft with
humans could be solved through control of design and instrument layout compatibility with pilots.
The massive application of HF in aviation started in the last 90-ties. The principles of HF were used
in investigation and during analysis of Aloha incident with B-737 in-flight break-up (1988). This
incident generated a deep understanding about maintenance human factors.
Evaluation of human personality impact on aviation safety resulted in “Aviation Safety Act” (year
1988) and special training manuals in Human Factors in Maintenance.

Statistics
According overall statistics nowadays, transport aviation is 98% safe. According to US National
Transportation Safety Board (NTFS) in year 2 000, it appeared in about 3 accidents to 1 000 000
departures in aviation or in overall 92 fatalities. The last year records show less than one fatal accident
occurring every 2 million flights. In turn, the same statistics for automotive transportation gives a
figure of about 41 800 fatalities.

Figure 1.1. Accident statistics

The Boeing “Statistical Summary of Commercial Jet Airplane Accidents. Worldwide Operations
1959-2011” (Fig. 1-1) shows comparison of the number of accidents to the number of departures.

Issue 1. Effective date 2017-03-20 FOR TRAINING PURPOSES ONLY Page 15 of 150
 Category B1/B2 according Part-66 Appendix 1 Module 9 Human Factors

It gives rise to the next conclusions:

1. Airline travels are very safe;
2. The safety rate is high and difficult to improve;
3. The slightly increased number of worldwide accidents almost does not influence the
statistics;
4. The regular aviation transportation in the USA, Canada and EASA countries is
extremely safe.

Other statistics from the same source concern Hull Loss Accidents (Fig. 1-2).

Figure 1-2. Hull Loss Accident – Worldwide Commercial Jet Fleet – 1990 through 1999

According to, the year 1990-1999 statistics show flight crews make the main income to fatalities.
Maintenance with about 6% takes the 4-th place only.
What can be cause of errors leaded to those accidents? It may be:
- Fatigue;
- Incomplete / Incorrect documentation;
- Personal problems;
- Fumes;
- Cold;
- Unrealistic deadlines;
- Neglecting of circadian rhythm and many other.

Normally only one factor does not make a problem. Mostly a problem arises from several factors
making a chain of events.
From the same BOEING study, it is seen before the HF was explicitly taken into account aviation
maintenance errors taken about 15% of total 9 583 lives of passengers and crewmembers (Fig. 1-3).
The comparison with Fig. 1-2 shows the consequent work in HF give results – maintenance causes
diminished twice. But in both tables about of 80% of these accidents are a result of human error!!!

Issue 1. Effective date 2017-03-20 FOR TRAINING PURPOSES ONLY Page 16 of 150
 Category B1/B2 according Part-66 Appendix 1 Module 9 Human Factors

Figure 1-13. All they were too complacent

There are a lot of other variations and consequences from Murphy law:

If there is any way to do it wrong, they will found it

If anything just cannot going wrong, it will anyway

If everything seems to be going well, you have obviously overlooked something

Things go worse under pressure

Nothing is as easy as it looks

All these jokes put on one’s guard against complacency and arrogance; they call for professionalism,
attention to details and changing conditions.

Issue 1. Effective date 2017-03-20 FOR TRAINING PURPOSES ONLY Page 30 of 150
 Category B1/B2 according Part-66 Appendix 1 Module 9 Human Factors

The ear has three divisions: outer ear, middle ear and inner ear (Fig. 2-7). These act to receive
vibrations from the air and turn these signals into nerve impulses that the brain can recognise as
sounds.

Figure 2-7. Ear structure

Outer Ear
The outer part of the ear directs sounds down the auditory canal, and on to the eardrum. The sound
waves will cause the eardrum to vibrate.

Middle Ear
Beyond the eardrum is the middle ear, which transmits vibrations from the eardrum by way of three
small bones known as the ossicles, to the fluid of the inner ear. The middle ear also contains two
muscles, which help to protect the ear from sounds above 80 dB (this is approximately equal to the
noise we can’t communicate normally at the distance of 1 m) by means of the acoustic or aural reflex,
reducing the noise level by up to 20 dB. However, this protection is provided for a maximum of about
15 minutes, and does not provide protection against sudden impulse noise such as gunfire. It does
explain (one reason of several) why a person is temporarily “deafened” for a few seconds after a
sudden loud noise.
The middle ear is usually filled with air, which is refreshed by way of the Eustachian tube, which
connects this part of the ear with the back of the nose and mouth. Such connection makes ear a kind
of differential Bellows, joint by the eardrum.
As the Eustachian tube is narrow enough, the airflow out and into the middle ear is slow enough and
could be disrupted. Under these circumstances (e.g. when aircraft change the flight altitude or during

Issue 1. Effective date 2017-03-20 FOR TRAINING PURPOSES ONLY Page 38 of 150
 Category B1/B2 according Part-66 Appendix 1 Module 9 Human Factors

9.3 SOCIAL PSYCHOLOGY

Social psychology is about understanding individual behavior in a social context. Baron, Byrne &
Suls (1989) define social psychology as:

social psychology - the scientific field that seeks

to understand the nature and causes of individual behavior in social situations

Each individual person could be characterized by his knowledge, abilities, physical and psychological
characteristics. These characteristics express themselves when begin interact with such “global”
factors as placed on Fig. 3-1.

Figure 3.1. The social environment factors

Direct Work Environment

The nearest to adult individual person is Direct work environment including:
- Physical environment;
- Supervisory environment;
- Organization (Company) culture;
- Regulations;
- Economic and political environment of society.

The “physical” part of the direct environment in aviation maintenance is related not only to hangar
and to other facilities, tools and equipment, but to aircraft design as well. These are designed for
keeping conditions suited for better performance and to fit existing regulations. The last is ensured
by regular audits.
Moreover, it includes such conditions as hangar/workshop temperature or climate conditions during
line maintenance.

Issue 1. Effective date 2017-03-20 FOR TRAINING PURPOSES ONLY Page 49 of 150
 Category B1/B2 according Part-66 Appendix 1 Module 9 Human Factors

The “supervisory” part of the direct environment consists of day-to-day planning, prioritizing tasks
and delegating duties, instructions given concerning particular task, team-building issues and on-job-
training, feedback given to managing directives, etc.

Company Culture
Every organisation or company employing aircraft maintenance mechanics will have different “ways
of doing things”. This is called the organisational culture.The company culture depends on:
1. Company philosophy and policy (business organization, staff incorporation into
decision-making, etc.);
2. Procedures (Management and public relation procedures, information dissemination,
management and work site arrangement, etc.);
3. Selection and training criteria (how personnel is selected, who and when is trained,
appointed to the post, etc.);
4. Quality assurance system (job assessment, working procedures, human error
management and reporting systems).

These factors are strongly company-dependent. It is important to understand how the organisation in
which the mechanic works might influence him, because the impact of the organisation may be
positive or negative (Fig. 3-2).

Figure 3-2. Organization influence

Organisations may encourage their employees (both financially and with career incentives), and take
notice of problems that their mechanics encounter, attempting to learn from these and make changes
where necessary or possible.
When motivating personnel, the lowest priority is given to the financial stimuli. Various investigation
showed the financial stimuli lasts no more than 3 (three) month. After this term personnel adapts and
the need in new financial stimulation appear. Carrier initiatives are more powerful stimulator up to
the moment when person began to feel he/she is fully satisfied by current position.

Issue 1. Effective date 2017-03-20 FOR TRAINING PURPOSES ONLY Page 50 of 150
 Category B1/B2 according Part-66 Appendix 1 Module 9 Human Factors

Talking about stress, we usually give him a negative aspect. What could be the negative factors
determining stress condition? – They could be external and internal (Fig. 4-2).

Figure 4-2. External and internal stress factors

From the other site, they are divided into physical, psychological and reactive factors or stressors
(Fig. 4-3).

Figure 4-3. Physical, psychological and reactive stressors

What are the first effects of negative stress situation? –Rising pulse and slightly rising temperature.
If the situation (stress) lasts, it shows serious physical and physiological reaction (Fig. 4-4).

Figure 4-4. Physiological and physical reactions to stress situation

Issue 1. Effective date 2017-03-20 FOR TRAINING PURPOSES ONLY Page 68 of 150
 Category B1/B2 according Part-66 Appendix 1 Module 9 Human Factors

Because stress cause such negative reactions, and almost all of surroundings could be the source of
stress, could we create a completely stress-free environment? In other words “Is it possible to improve
the overall work performance if working in a completely stress free environment?”
What is a stress-free environment? Here is the story posted by Sam Biddle titled “The Quietest Place
on Earth will drive you insane within 45 minutes”:
“There is a small room in Minnesota that blocks out 99% of all external sound (Fig. 4-5). That is an
impressive number! Also impressive: nobody can take more than 45 minutes alone in the room before
they go nuts.

Figure 4-5. The anechoic room in Minnesota, USA (Photo by Steven Orfield)

The Daily Mail describes Orfield Labs' anechoic chamber - perfect for making extremely sensitive
audio measurements. Also perfect for sending you into a hallucinatory hell so hellacious you will
need a chair:
“When it's quiet, ears will adapt. The quieter the room, the more things you hear. You will hear your
heart beating, sometimes you can hear your lungs, hear your stomach gurgling loudly. In the anechoic
chamber, you become the sound.”
This is a very disorientating experience. Mr. Orfield explained that it is so disconcerting that sitting
down is a must. He said: “How you orient yourself is through sounds you hear when you walk. In the
anechoic chamber, you do not have any cues. You take away the perceptual cues that allow you to
balance and maneuver. If you're in there for half an hour, you have to be in a chair.”

Issue 1. Effective date 2017-03-20 FOR TRAINING PURPOSES ONLY Page 69 of 150
 Category B1/B2 according Part-66 Appendix 1 Module 9 Human Factors

9. 7 COMMUNICATION
Communication is a very interesting and important process. Nevertheless, people understand
communication process in different ways. In many cases these differences in understanding lead to
misunderstanding and failed communication resulting by various mistakes.
To avoid misunderstanding start with communication definition first.

Definition of Communication
One of the well-known definitions of communication is that of given in Penguin Dictionary of
Psychology:
Communication - the transmission of something from one location to another.
The “thing” that is transmitted may be a message, a signal, a meaning, etc.

According to this definition, communication may be assigned as a one-way process of transmitting

information from one person to another, or when superiors just communicate their decisions to
employees not bothering if that decisions are accepted or not.

To eliminate the problem of rejected information (in communication process) and thus, failed
communication, another definition may be proposed:

Communication is a two-way process of reaching mutual understanding,

in which participants not only exchange (encode-decode) information, news, ideas and feelings
but also create and share meaning

According to this definition if shared meaning is not created, we have an obvious case of failed
communication.
In any case working together for communication to be effective it requires common elements. Good
communication is important in every industry. In aircraft maintenance, it is vital. Misunderstandings
and communication failures are important in the whole life, at work as well as in personal (Fig. 7-1).

Figure 7-1. The consequences of poor communication

Issue 1. Effective date 2017-03-20 FOR TRAINING PURPOSES ONLY Page 111 of 150
 Category B1/B2 according Part-66 Appendix 1 Module 9 Human Factors

Communication Elements
Clear communication can be the difference between getting a job at the first time, or expensive re-
work; doing the job safely or injury to personnel.
To communicate effectively we need know some basic principles of communication based on the
simple understandable model of communication (Fig. 7-2).

Figure 7-2. A simple model of communication

We are communicating:
- Information;
- Ideas;
- Feelings;
- Attitudes and beliefs.

As the senders of a message, we typically expect some kind of response from the person we are
communicating with (the recipient – “Receiver” or listener), which could range from a simple
acknowledgement that this message has been received (and we hope it was understood), to a
considered and detailed reply. The response constitutes feedback.
It looks rather simple, but why communication is so difficult? Why there are so many communication
errors?
Look at the possible communication channels first.

Communication Channels
When talking about communication we think about oral (spoken) communication first, but, in aircraft
maintenance a lot of communication is not a spoken communication. Maintenance is heavily reliant
on documentation – logbooks, various maintenance manuals and part catalogs. Information is
transferred through various graphs, symbols. We accompany speech by gestures and attitudes (body
language) that constitutes non-verbal cues.

Issue 1. Effective date 2017-03-20 FOR TRAINING PURPOSES ONLY Page 112 of 150
 Category B1/B2 according Part-66 Appendix 1 Module 9 Human Factors

9. 8 ERRORS
Many aircraft accidents are related to maintenance errors. Up to 30% of engines in-flight shut-downs
relates to maintenance problems. All of us being airlines passengers sometimes were rebelled by
flight delay. We learn about delay of charter flights – a lot of them due to engine problems. Up to
50% of such problems related to flight delay and cancellation are due to maintenance errors.
Humans make errors and that will never change. We have studied some possible error sources in
“Human Performance and Limitations” related to humans physical aspects and brain functioning.
Relating to error we only could minimize their occurrence and aftereffects. To minimize error
occurrence is a matter of safety and cost. Indeed, it is pride when you make a little errors or they are
only the small one. This is difficult if we do not understand error itself. Such understanding starts
from definition, which gives us correct direction to error understanding and minimization.

Errors Models and Theories

Errors may be defined differently as:
- An unsafe act unintentionally committed, or
- A wrong action attributable to bad judgment, ignorance, or inattention.

Professor Reason’s Swiss cheese model also know as “The Window of Opportunity” is theoretical
model that illustrates how accidents occur in organizations (Fig. 8-1).

Figure 8.1 Swiss cheese model

The model focuses on both organizational hierarchy and human error. It states that the typical accident
occurs because several (human) errors have occurred at various levels in the organization in a way
that made the accident unavoidable.

Issue 1. Effective date 2017-03-20 FOR TRAINING PURPOSES ONLY Page 129 of 150
 Category B1/B2 according Part-66 Appendix 1 Module 9 Human Factors

Types of Errors in Maintenance Tasks

Maintenance presents many possibilities for errors. While disassembling tasks are rather simple and
give rare possibility to err, reassembly gives a lot. A bolt with eight nuts is a classic example by prof.
James Reason (Fig. 8-2) – there is only 1 (one) possibility to disassemble nuts but more than 40 320
opportunities to miss the previous order when assembling them back. The nowadays aircrafts like
Boeing or Airbus present much more opportunities for errors.

Figure 8-2. This combination of a bolt and marked nuts gives 40 320 combinations of re-
assembling

The Reason model of errors differs between errors made after unintended or intended actions (Fig.
8-3).

Figure 8-3. Reason model of errors

After identifying the type of error, the possible correction action may be developed. In the case of
unintended error we could find ourselves doing a task in a way we never thought about (a slip) or we
leave out a required step (a washer do not installed) making a lapse. These errors typically occurs
when our attention is distracted.
Mistakes are related to “bad” plan executed due to bad knowledge, use of incorrect procedure or skill.
Intended action in most cases do not means that the person intended harm. Intended actions can be
divided into “mistakes” and “violations”. Fig. 8-3 shows that “mistakes” may arise both from
unintended and intended actions.

Issue 1. Effective date 2017-03-20 FOR TRAINING PURPOSES ONLY Page 135 of 150
 Category B1/B2 according Part-66 Appendix 1 Module 9 Human Factors

9.9 HAZARDS IN THE WORKPLACE

Each work has its own hazards. When you working as aviation maintenance mechanic or in a
workshop, there may be various hazards depending on your job. A long use of pneumatic rivet gun
can influence your hearing, welding can affect vision; you can inhale noxious fumes or fall from
significant height.
To avoid such possibilities you must know how to avoid and deal with hazards at workplace.

Recognizing and Avoiding Hazards

Thus, the sample list of hazards in maintenance environment (both line, hangar and workshop) could
be as follows:

Maintenance Hazardous object/job Hazard

Line Maintenance
Base Maintenance
Workshop/Other
Propellers/Rotor blades Propeller/Rotor strike
Jet engines Intake suction
Jet blast at max trust
Hydraulic systems Hydraulic fluid squirted into the eye
Movable surfaces Caught in/under/between
Pneumatic riveting Loud sound
Wing or empennage, stairs Fall from
Aircraft bathing or painting Vapor inhalation or ingress of moisture
Hydraulic systems Hydraulic fluid squirted into the eye
Oxygen Burning while contacting petroleum
products
Movable surfaces Caught in/under/between
Welding Very bright lights
Parts bathing/painting Vapor inhalation or ingress of moisture
Mechanical processing Caught in/under/between
Composite processing Dust inhalation and skin adsorption

Issue 1. Effective date 2017-03-20 FOR TRAINING PURPOSES ONLY Page 141 of 150
 Category B1/B2 according Part-66 Appendix 1 Module 9 Human Factors

Propeller / Rotor

The propellers / rotors are difficult to see while turning especially when being distracted and forget
about the danger. Most blades are marked in yellow on the tip but when distracted or being under
stress (domestic or work related) you can forget that.
Avoiding hazard:
- Follow rules to correct approach (leave) of propeller aircraft;
- Do not approach from the front wing side;
- Approach to helicopter from the side.

Jet Engines

Working jet engine creates a strong suction in front of engine and jet blast at the rear. The first one
can suck into engine and killing yourself if being too close, or suck a foreign object (plier, wrench,
etc.) causing a damage and huge financial loses (an engine of a large aircraft can cost up to several
million dollars).
Avoiding hazard:
- Do not approach working jet engine straight nearer that approximately 7-8 meters;
- The distance to straight approach to jet engine working at full trust shall be not less that about
50 meters.

Issue 1. Effective date 2017-03-20 FOR TRAINING PURPOSES ONLY Page 142 of 150